Broken arm, laceration, back pain, back pain, back pain. Working in fast track can become very routine and the days can start to blend in with one another.
By the end of a shift, providers may develop the fast track mindset of “what does this patient need and how fast can we get it to them so they can be discharged?” Although this mentality can work great for straightforward cases, it can be very dangerous if there is a life-threatening case disguised as a fast track.
While it can be nearly impossible to pick up on every single one of these patients, here are three questions every clinician should ask themselves in order to catch a mistriaged case:
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Do the history and physical agree with one another?
If the history leads you to a certain diagnosis, and the physical leads you to this same diagnosis, it is often okay to assume that the patient has this said diagnosis. But sometimes you are presented with a patient whose story just doesn’t make sense, and this is when you need to trust your instincts.
A couple of weeks ago a healthy young male presented with sudden onset of centralized chest pain that had occurred five days prior. It was constant, boring, and nonreproducible with movement or palpation.
While my first instinct was to chalk it up to chest-wall pain, because he was a young healthy male with no past medical history, the story just didn’t make sense to me.
The pain was constant, lasted for five days, and the patient could tell me the exact moment it began. This sounded like it might be something a little more than musculoskeletal, and I decided I had to work him up further.
Do the numbers support or refute your diagnosis?
What are the patient’s vital signs? No patient with a combination of tachycardia and hypertension belongs in fast track. Ever.
If you find that you have a patient with abnormal vitals, you cannot assume this is their baseline. You must find the source of these unusual numbers before they can be discharged.
My aforementioned patient had a pulse of 104. While it was not an alarmingly fast heart rate, it was faster than it should have been for a healthy, young male. If anything, he should have been slightly bradycardic due to his athletic lifestyle.
After running some labs, it was found that his d-dimer was 220. Again, this number wasn’t alarmingly high, but it was higher than it should have been. These numbers did not sit right with me and I decided it was time for some imaging.
Will you be second guessing your decisions?
When it comes to ordering labs and diagnostics on a patient, my rule is simple: Will I be thinking about them on my drive home, wishing I had run the test?
If the answer is yes, then I order the test. This is particularly true with tests like CTAs and CTs of the neck. These tests can provide large doses of radiation, so I like to use them sparingly, especially with my younger patients.
I was hesitant to order the CTA for my patient. If the test came back negative, I would have dosed him with a large amount of radiation. But with the history, the physical, the tachycardia, and the elevated d-dimer, I could not let him go without working him up for a pulmonary embolism. I would have definitely been thinking about him on my ride home, wishing I had ordered the test. So I went ahead and got ordered the CTA.
The result? A large bilateral pulmonary emboli. Although this was my first case of a PE in fast track, I am sure it will not be my last.
This case served as a continued reminder to trust my instincts. If the history and physical don’t agree with each other, I probe further. If the vitals or labs are unexplainable, I dig deeper. And if I know I’m going to second-guess foregoing a test, I order it.
These ideas help me pick up on the true medical emergencies disguised as fast-tracks, and they make my drive home a lot more enjoyable.
Jillian Knowles, MMS, PA-C, is an emergency medicine physician assistant in the Philadelphia area.
